Many GPs are finding that size does matter when it comes to winning contracts and delivering modern services. Nigel Hawkes reports

General practice has often been told it needs to change. But exactly how is less clear. Everybody seems ready to define and redefine the problem, but fewer are willing to say how to solve it.

Take NHS England’s Improving General Practice—a Call to Action, published late last year.1 Any GP reading this would struggle to discover what action was actually being called for, as the document describes ends but not means. It was followed by a very similar call to action for London, where the problems are seen as the most acute. One chapter was headed, “More needs to be done.” Yes, but what? What can GPs convinced by the arguments actually do?

The current answer is that GPs cannot deliver modern services without a bigger footprint. Merging with other practices is unattractive, so the alternative is to form networks or federations, shedding some independence in order to gain weight. This idea was first proposed in 2007 by the Royal College of General Practitioners (RCGP)2 to counter one of the few reports that did include a plan: Lord Darzi’s polyclinic vision for London.3 “We caution against the development of ‘super surgeries’ or disease-focused ‘polyclinics,’ which simply co-locate individuals without an underpinning philosophy or vision,” said the college, though its real fear may have been that general practices would be swept aside by private companies bidding for polyclinic contracts.

What is the driver?

Maureen Baker, chair of the RCGP, says the call for federations was inspired by the desire to preserve “so much that’s good about primary care” while enabling change. “We wanted to keep practices as the basic unit of care instead of corralling doctors into new city centre …